Somebody call a doctor: the Senate’s healthcare bill seems on life support following another round of defections by Republican senators. The rush for the exits came after Monday’s forecast by the non-partisan Congressional Budget Office, which predicted the healthcare bill would result in 22 million fewer Americans without insurance by 2026. It also said older Americans—obviously heavy users of healthcare—would be slammed with huge premium increases, way beyond what they’d face under the current Obamacare system that Republicans call a disaster.

Even before the report came out, Democrats had been hammering away, pointing out the GOP bill would shaft Americans—by slashing Medicaid by hundreds of billions of dollars. The Republican response: What cuts? Medicaid isn’t being cut.

How can two groups look at one thing and have two wildly different answers? It’s either being cut, or it’s not, right?

But in a way, both are right on this one point. Current Medicaid spending in fiscal year 2017, which ends September 30, is $393 billion. In fiscal year 2026, it’s projected to be $624 billion. That’s an increase of 59%, or 6.5% a year over the next nine years.

The way Republicans see it, that’s not a cut, it’s a huge increase, and mathematically, they’re right. That 6.5% annual growth far outstrips both projected economic growth, and projected tax revenues. In other words, Medicaid—a crucial lifeline for millions of Americans—is expanding a lot faster than our ability to pay for it, and that theory can also be extrapolated, by the way, to Medicare and Social Security.

The dilemma: All three of these crucial programs can literally mean life or death for the most vulnerable among us. Yet they’re gobbling up more and more of the federal budget each day—about 60% of all spending now—and the percentage is growing. You can’t have gargantuan spending programs growing faster than the economy in perpetuity. At some point, something’s got to give.

But the way Democrats see it, Medicaid would actually be cut—and mathematically this argument is correct as well. That’s because both the House and Senate plans propose to slash what’s known as the “federal match rate” that currently finances Obamacare’s Medicaid expansion in 31 states. The only difference is that the House wants to kill the match almost immediately—by the end of 2019—while the Senate would do so at a more gradual rate. Unless those 31 states make up the difference—not likely—millions of Americans will suffer. This isn’t hyperbole: there are fears that low-income parents may not be able to afford neonatal care for newborns , and that seniors could be ousted from nursing homes.

So the healthcare debate is about more than healthcare. It’s also about entitlement spending, how fast the economy is growing, how wide and deep our tax base is, the time frame through which we examine issues and so forth. All this stuff is intertwined in a big, messy way that defies the kind of binary arguments we see in TV every day, where issues are either “good” or “bad.” We should start by acknowledging two central and painful facts that are at odds with one another. First, we’re living way beyond our means as a nation. Second, millions of Americans are largely at the mercy of insurers and state/federal law to provide the regulatory framework for affordable healthcare.

In other words: We can’t afford healthcare—but we can’t afford not to have it.

Since we’re talking about being healthy, long-term fiscal responsibility is vitally important—a matter of national security. For this reason, I’d be inclined to say that any attempt to “bend the curve” on Medicaid growth is a painful step in the right direction. But Republicans get no credit here, since both of their plans propose not just entitlement cuts—but also massive tax cuts for high-income Americans.

The GOP argument goes like this: Democrats raised taxes on the wealthy to fund Medicaid’s expansion. But since we’re doing away with the “federal match rate” that financed that expansion, we’re going to give the rich their money back. In other words, let’s pull the rug out from under the most vulnerable, while stuffing billions into the pockets of the most invulnerable. Talk about both stupid and greedy.

What about President Trump? The funny thing here is that while ditching Obamacare plays to his base—it was a huge campaign promise—his base forgets that he also promised to preserve Medicaid. The joke’s on them. About 45% of all voters last year were age 50 or older, and about 53% of them went for Trump. Yet they’re the ones who are going to pay, literally, a giant price if the GOP gets a healthcare plan through. It’s not just the yuge premium increases mentioned earlier, but also the loss of thousands of dollars in tax credits. Pay more, get less? I’m pretty sure that’s not what Trumpsters voted for—I’m also pretty sure that’s not how you make America great again.

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